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PTSD Treatment Via
Telemental Health Technology
Leslie A. Morland, Psy.D.
San Diego VA Healthcare System
National Center for PTSD - Pacific Island Division
UCSD, Department of Psychiatry
Acknowledgements
This work was partially supported by grant DHI 07-259 from
the Veterans Affairs Health Services and Development
(VAHSR&D) and partially supported by Grant PT07456,
PT090552, PT110021 from the Department of Defense.
This work is also supported by the Office of Research and
Development, Medical Research Service, Department of
Veterans Affairs. All views and opinions expressed herein
are those of the authors and do not necessarily reflect
those of our respective institutions or the Department of
Veterans Affairs.
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Objectives
• PTSD Prevalence
• Access & Barriers to PTSD Care
• A New Paradigm: Potential of Technology
• Clinical and Research Updates
• New Directions
Mental Health Care Demand
• 18.3% of American adults are diagnosed
with mental health disorder (SAMHSA,
2016).
• Six in ten Americans living with psychiatric
disorders are not getting mental health
treatment.
PTSD Prevalence
• 23.5 % prevalence rate of PTSD among
veteran returning from Iraq or Afghanistan
(Fulton et al., 2015).
• PTSD evidence-based psychotherapies (e.g.,
PE, CPT, EMDR) significantly reduce PTSD
symptoms in veterans.
PTSD Treatments works but…
• Despite evidence of the efficacy of psychotherapy, it is
substantially underutilized in the US and the VA (Lu et al.,
2016; Mott et al., 2014 and Shiner et al., 2013).
• Access and utilization of EBP is even more limited in
rural/geographically remote areas (Grubbs et al., 2017;
Morland et al., 2013).
Efforts to modify clinic structure, training efforts, and
wider availability of EBPs have been successful in
increasing utilization (Hundt et al., 2017).
PTSD Treatments works but…
• Low rates of new patients with PTSD begin
psychotherapy in VHA Those who start, receive low-
intensity dose of treatment (Mott, 2014).
• Approximately half of OEF/OIF/OND veterans surveyed
who may have a need for mental health care services do
not use VA or non-VA mental health care services (Jan
2018, Consensus Study Report)
• The process of accessing VA mental health services has
been burdensome and unsatisfying for many
OEF/OIF/OND veterans. (Jan 2018, Consensus Study Report)
Status Quo: Barriers
Veterans in need of Mental Health resources often face a number of barriers including:
• Geographic distance
• Physical mobility
• Time/schedule constraints
• Desire for Cost
• Privacy
• Cultural value of self-reliance
• Ambivalence
• Stigma
The newest cohort of Veterans increasingly expects “on-demand” services.
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A New Paradigm of Care
• Need for flexible models of care delivery that
meet patients where they are physically and
psychologically (Hoge, 2011; Kazdin, 2011).
• Need for innovative way to “engage” patients
clinically and allow for “patient-centered” care.
• Need to find a way to incorporate
treatment gains and skills into
everyday practices.
Why Use Technology
Expand
Access
Increase
Engagement
Improve
Efficiency
Technology Across the
Continuum of Care for PTSD
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Technologies of Interest their
potential for PTSD Care
• Clinical Videoteleconferencing (CVT or TMH)
• Access, ease of access, family involvement
• Web Based Interventions
• Education, Awareness, Self-management & self
monitoring
• mHealth Technologies - Mobile App
• Between session work, allow for real time
intervention
Current Opinion in Psychology 2017, 14:102–108
Telemental Health for PTSD
• Increased access
• Lower cost without lower quality
• Reduced patient burden
• Travel time; transportation costs
• Missed employment time
• Patient-centered model
• May reduce shame/stigma barriers
Why use TMH for PTSD?
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Evidence for TMH and PTSD:
What do we really know?
• Clinical outcomes are similar to in-person
across therapies and treatment settings
(Backhaus et al., 2010)
• Established Efficacy of TMH for
• CPT in group (Morland et al., 2014)
• CPT Individual (Morland et al., 2015)
• PE (Tuerk, et al, 2010)
• Collaborative Care (Fortney et al., 2015)
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Take Home Message:
TMH modality works!
• Acceptability
• Equivalent clinical outcomes
• Virtually equivalent process
outcomes
• Cost effective
• Comparable Treatment Fidelity
• Clinician training
Telemental Health Growth FY02-16
Challenges to Traditional
Office-Based TMH Model
• Increases access but not necessarily as
efficient or engaging
• Geographical barriers still exist
• Cost associated with staff time
• Coordination requirements
• Space needs
• Sustainability?
Home-Based CVT Model of Care
VA Hospital (Provider) VA Clinic (Veteran)
Home (Veteran)
Home-Based TMH
Home-based CVT
Benefits:
•Increases access & convenience
•Increase engagement
•Less stigma
•After hours flexibility
•Reduce no shows rates
Challenges:
HIPAA, licensing
Veteran Case Example
Face to Face
Appointment
HB-CVT Appointment
• Veteran leaves home 7am
• Drives to clinic 7-830am
• Parking & shuttle 830-9am
• Check in 845-9am
• Session 9-10am
• Shuttle to parking 10-1030am
• Drive home 1030am-12pm
• Total time : 5 hours
• 9am Veteran logs on and
provider calls
• Session over 10am
• Total time: 1 hour
Evidence for HB-TMH and PTSD:
What do we know?
• Feasible, safe, effective • Active Duty US Military (Luxton et al., 2015)
• Veterans (Shore et al., 2014; Yuen et al., 2015)
• Comparable process outcomes to traditional
office-based care • Satisfaction among patients undergoing Prolonged Exposure
(Gros et al., 2016)
• Comparable clinical outcomes to traditional
office-based care • BA & Exposure (Acierno et al., 2016)
• Psychotherapy for dep. in older adults (Egede et al., 2015)
• Prolonged Exposure (Acierno et al., 2017)
Big Picture
• New Model of Care in VA
• Established Clinical effectiveness of Home-
Based CVT
• Potentially increased cost effectiveness?
• Reduced no-shows?
• Reduced travel reimbursement?
• Reduced overhead costs?
• Reduced “missed opportunities”?
Frequently Asked
Implementation Questions
Home-Based TMH Care
•Patient Selection
•Technology Availability
•Ability to assess risk
•Ability to establish safety and emergency plan
•Clinical guidelines & behavioral expectations
•Concern re collusion with “Avoidance”
What Do Veterans Want? A
Preliminary Look at
Veterans’ Preferences
Where do Veterans want their care?
30%
42%
27%
In-Home In Person Home-Based Telemed Office-Based Telemed
Treatment Delivery Modality Preference
Moving Forward: Future
directions yet to be examined…
• What is the optimal level of therapist interaction with technology (web, mobile apps) - hybrid models of care
• How do we determine “the-fit” between the patient, the technology and the system of care? - patient preferences, safety concerns
• How can technology be best integrated into traditional care vs a “new model of care”?
• How can we capture utilization and reach?
• Billing, safety, quality control
What is the Potential of
Technology for PTSD
Technology has the potential
to change the landscape of
how we deliver mental health
services, specifically for
PTSD, and may offers a path
toward improving the access,
engagement and efficiency of
trauma-related interventions.
mHealth Technologies
Engage
Self-monitor &
self-manage Educate
Raise Awareness
• Given the anticipated spread of these
technologies around the world in the next
decade, they hold promise of making a
significant contribution to reducing the burden
of mental health demand.
• Technology can allow for service provision
across space & time and can be a game-
changer for mental health care in the 21st
century.
Summary
SAVE THE DATE: Third Wednesday of the Month from 2-3PM (ET)
UPCOMING TOPICS
(866) 948-7880 or [email protected]
March 21 What We Know about PTSD and Opioids Elizabeth Oliva, PhD & Jodie Trafton, PhD
April 18 Balancing Clinical Flexibility while Preserving
Efficacy in Delivering EBPs for PTSD
Tara Galovski, PhD
May 16 Brief Prolonged Exposure for PTSD Sheila Rauch, PhD
June 20 What the Latest Research Tells Us about Treating
PTSD Nightmares
Philip Gehrman, PhD
July 18 The Continuum of Care for PTSD Treatment Kelly Phipps Maieritsch, PhD
August 15 An Evidence-Informed Approach to Helping
Clients after Disaster or Mass Violence: Skills for
Psychological Recovery
Patricia Watson, PhD
September 19 PTSD and Women’s Mental Health Suzanne Pineles, PhD
For more information and to subscribe to announcements & reminders go to www.ptsd.va.gov/consult